Scenario A (Questions 1-8): \"This 85-year-old man is admitted for treatment of

Question

Scenario A (Questions 1-8): "This 85-year-old man is admitted for treatment of pneumococcal pneumonia. At the time of admission, he was also complaining of severe back pain with no recent accident or trauma. IV antibiotics were started for the pneumonia, pain medication for the back pain, and a CT scan of the lumbar spine was completed. The radiology report indicated that the patient had a fracture of the L4-5 vertebrae, however, the attending physician did not note these findings in the health record. Discharge diagnosis was documented as: Pneumococcal Pneumonia with severe low back pain."

What are the discharge diagnoses documented in the scenario? Check all that apply:

?Pneumococcal pneumonia   ?Pain medication ?Back pain ?Fractured vertebrae

Is any diagnosis a symptom whose underlying cause may have been confirmed but not documented??Yes ?No

If so, which diagnosis??Back pain?Pneumonia?Fever?Trauma

Does the record contain additional information about that condition?

?Yes ?No

If so, what information??History and physical?Radiology report

?Operative report    ?Laboratory report

Can inpatient coders assign codes based on a radiology report??Yes ?No

What information is missing?

?Symptoms of the patient   ?Underlying cause of the back pain   ?Allergies to medication   ?History and physical report

How can the coder obtain the missing information??Contact the patient

?Add it to the report    ?Search the patient records    ?Query the provider

Explanation / Answer

1. discharge diagnosis : pneumococcal pneumonia, back pain

2. yes

3. back pain

4. yes

5. radiology report

6. yes

7. history and physical report (the history of the patient can be cause of the fracture)

8. contact the patient and query the provider

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